For prognostic reasons, severly comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group.

Presentation

Symptoms

pain, inability to bear weight, deformity

Physical exam

inspection and palpation

deformity / angulation / malrotation

contusions

blisters

open wounds

compartments

palpation

pain

passive motion of toes

intracompartmental pressure measurement if indicated

neurologic

deep peroneal n.

superficial peroneal n.

sural n.

tibial n.

saphenous n.

pulse

dorsalis pedis

posterior tibial

be sure to check contralateral side

Imaging

Radiographs

recommended views

full length AP and lateral views of affected tibia

AP, lateral and oblique views of ipsilateral knee and ankle

CT

indications

intra-articular fracture extension or suspicion of joint involvement

CT ankle for spiral distal third tibia fracture

to exclude posterior malleolar fracture

Treatment of Closed Tibia Fractures

Nonoperative

closed reduction / cast immobilization

indications

closed low energy fxs with acceptable alignment

< 5 degrees varus-valgus angulation

< 10 degrees anterior/posterior angulation

> 50% cortical apposition

< 1 cm shortening

< 10 degrees rotational malalignment

if displaced perform closed reduction under general anesthesia

certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery

technique

place in long leg cast and convert to functional brace at 4 weeks

outcomes

high success rate ifacceptable alignmentmaintained

risk of shortening with oblique fracture patterns

risk of varus malunion with midshaft tibia fractures and an intact fibula

QUESTIONS

(OBQ13.120)
A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. He was transported to a Level I trauma hospital where he was given intravenous antibiotics and tetanus at 10:45PM. He underwent irrigation and debridement of the wound with 9L of saline solution and was treated with reamed intramedullary nail fixation at 11:45PM. A vacuum assisted dressing was placed over a 5x3cm skin deficit. What part of his overall treatment has shown to reduce the risk of infection THE MOST at the site of injury?Review Topic

The most important factor shown to reduce the risk of infection at the site of an open fracture is early intravenous antibiotic administration.

Infection risk after Gustilo Type II open fractures ranges from 10-20% in large studies. Antibiotic treatment initiated within 3 hours from the time of injury has shown to significantly reduce the rate of infection. Antibiotic coverage for Type II open fractures should cover gram positive bacteria. Soil-contaminated wounds should include anaerobic coverage. The dose of antibiotic given must be within a therapeutic range and titrated to the patient's weight (e.g. Ancef 2 g IV for >70 kg). Duration of antibiotic therapy has been suggested to be between 1 and 3 days, although there is no agreement on a firm end point.

Pollak et al. reviewed a large cohort of open fractures treated at Level I trauma centers. They demonstrated a significant decrease in infection rate with either early direct admission (<2 hours) or transfer (<11 hours) for ONLY type III open tibia fractures. They did not not discuss timing of antibiotic treatment because this was not prospectively collected. Although they did not collect data on antibiotic treatment, the authors theorize that early transfer potentially resulted in earlier administration of antibiotics.

Patzakis et al. examined a series of 1104 open fractures to determine the factors contributing to infection. They showed the most important factor in reducing the infection rate was the early administration of antibiotics.

Illustration A is table showing the Gustilo classification of open fractures.

Incorrect Answers
Answers 1,4: These responses have been shown to reduce the risk of infection in open fractures, however, the most important factor has been shown to be early antibiotic therapy.
Answer 3: Reamed intramedullary nailing has not been shown to decrease infection risk in open tibia fractures, however, skeletal stability will prevent ongoing soft tissue damage
Answer 5: Vacuum-assisted wound dressings (or negative pressure wound therapy) are controversial as to whether they provide any protective effect against infection.

(OBQ13.211)
A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. Radiographs are seen in Figures A and B. You decide to treat this fracture with intramedullary nailing. In order to prevent a missed injury that should be addressed during the same surgery, you order the following test Review Topic

This patient has spiral distal tibia and proximal fibula fractures. Dedicated imaging of the ankle should be performed to exclude a posterior malleolus fracture. Imaging options include either dedicated ankle radiographs or CT scans.

Tibial shaft fractures arise from high- or low-energy injuries. Low-energy injuries are characterized by (1) torsional mechanism of injury, (2) spiral pattern, (3) fibula fracture at a different level. Surgical options for closed shaft fractures include IM nailing and plate fixation. Concomitant ankle fractures should be treated during the same surgery to improve outcome.

Boraiah et al. examined the association of posterior malleolus fractures with spiral distal tibial fractures. They found that 39% had posterior malleolus fractures. In simple fractures (92%), none of the posterior malleolar fracture lines were contiguous with the diaphyseal fracture lines. In comminuted fractures (8%), an occult fracture line extended into the posterior tibial lip. Diagnosis was missed in 5% before CT scanning was initiated, and 0% after.

Figures A and B are AP and lateral radiographs showing a spiral distal tibial fracture with a proximal fibula fracture. Illustration A is an axial CT scan showing the posterior malleolar fracture not seen on plain radiographs. Illustration B shows a missed posterior malleolar fragment in a fracture treated with IM nailing that subsequently displaced.

Incorrect Answers:
Answers 1, 2, 3, 5: There is no association between spiral distal tibial fractures and injuries of the hip, knee or calcaneus.

(SBQ12.9)
A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He is also noted to have a grade 1 splenic laceration and lung contusion. He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. The use of a tourniquet in this case has been most clearly shown to be associated with which of the following?Review Topic

Karunakar et al showed in a canine model that there is no significant difference in the heat generated during reaming with and without a tourniquet. The factor that made the most difference was related to the size of the reamer used compared with the diameter of the isthmus. They concluded that the risk of thermal necrosis appears to be related more to the process of intramedullary reaming than to the tourniquet.

Giannoudis and associates performed a prospective randomized trial on 34 patients to measure the rise of temperature during reaming of the tibia before intramedullary nailing with and without the use of a tourniquet. The factor that generated the most heat was using large reamers (11 mm to 12 mm) in a patient with a small isthmus (8 mm to 9 mm). Use of a tourniquet, steroid use, and knee flexion during reaming were not shown to be associated with diaphyseal necrosis after reamed tibial nailing.

Pollak et al evaluated the association between femoral nailing followed by tourniquet ischemia and clinical lung injury. They reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation over a six year period. All femoral shaft fractures were treated with reamed intramedullary nails, and the patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with or without a tourniquet. They noted increased pulmonary morbidity in the group where a tourniquet was used.

Figure A shows a femoral shaft fracture at the junction of the middle and proximal one-third of the femoral shaft. Figure B shows a contralateral tibial shaft fracture.

Incorrect Answers:
1-Tourniquet use has not been shown to lead to thermal necrosis of the bone during reaming of the tibial shaft.
3-The cortical temperature does not increase to a greater degree with tourniquet use versus non-tourniquet use during reaming.
4-There is no evidence that use of a tourniquet affects tibial shaft union rates after reaming and intramedullary nailing.
5-Tourniquet use has been associated with increased pain post-operatively.

Figure B shows a midshaft tibia fracture with an intact fibula, which places the fracture at increased risk of varus malalignment during healing.

Nonsurgically treated tibial shaft fractures with an intact fibula have an increased risk of varus malunion when treated nonsurgically. The fibula acts as a strut, preventing valgus collapse, but predisposing to varus angulation. Limb-length discrepancies can also occur.

Teitz et al. found that 26 percent of patients over the ago of 20 years old with isolated tibial shaft fractures treated nonsurgically went on to varus malunion. They also found that when the fibula remains intact, a tibiofibular length discrepancy can develop and cause altered strain patterns in the tibia and fibula leading to later ipsilateral joint sequeale.

Bonnevialle et al performed a retrospective study to assess the outcome after reamed nailing of tibial fractures with an intact fibula. Thirty-eight fractures were evaluated at a minimum of one year from surgery. Healing was achieved after the first intention treatment in 30 patients, after dynamization in 6. A non-union in 2 patients was also successfully managed with new nailing and dynamization. The authors concluded that nailing is a reliable technique for the treatment of tibial fractures with an intact fibula.

Sarmiento et al reviewed 1,000 consecutive closed diaphyseal tibial fractures, treated with prefabricated functional below-knee braces, to determine factors predictive of final fracture outcome. They found that final angulatory deformity in any plane was < or = 6 degrees in 90% of patients. They also noted that the presence of an intact fibula was a relative contraindication for functional fracture bracing because angulatory deformity was more likely to develop.

Incorrect Answers:
Answer 1: Figure A shows a distal tibia and fibula fracture which are not specifically prone to varus malunion. Rather, if treated with IM nailing, fracture alignment is dictated by placement of the guide-wire and path of reaming which must be center-center distally.
Answer 3: Figure C shows a midshaft fibula and tibia fracture at the same level. The fibula, in this case, would not predispose the fracture specifically to varus malalignment.
Answer 4: Figure D shows a proximal tibial shaft and associated fibula fracture. This fracture pattern is predisposed to valgus and procurvatum.
Answer 5: Figure E shows a segmental tibial shaft fracture which are prone to shortening, translational, and rotational malalignment.

The center of rotation of angulation(CORA) in diaphyseal tibial deformity is defined as the intersection of the proximal mechanical(PMA) or anatomical axis(PAA), and the distal mechanical(DMA) or anatomical axis(DAA).

Angular deformity of the femur or tibia involves angulation not only of the bone but also of its axes. When a bone is divided and angulated, the mechanical and anatomic axis of the bone are also divided into proximal and distal segments. The pairs of proximal and distal axis lines intersect to form an angle. The point at which the proximal and distal axis lines intersect is called the CORA.

The axis line of the proximal bone segment is called the PMA or PAA, and axis line of the distal segment is called the DMA or DAA. In the tibia, because the mechanical and anatomical axes are almost the same, the PMA and PAA lines overlap, as do the DMA and DAA lines.

Illustration A shows the CORA as it relates to the axes of an angulated tibia.

Incorrect Answers:
2-5:These do not describe the CORA or any other specific anatomical points as they related to long bone deformity.

(OBQ12.185)
A 21-year-old male undergoes intramedullary nailing of the closed tibial shaft fracture shown in Figure A. At his 6-week follow-up, he is noted to have peroneal nerve deficits that were not present preoperatively. Which of the following findings is most consistent with a diagnosis of transient peroneal nerve neurapraxia as the result of his intramedullary nailing?Review Topic

Transient peroneal nerve neuropraxia has been noted in up to 5% of patients undergoing closed nailing of tibial shaft fractures. This is of unknown etiology, although injury to the peroneal nerve branches can be from placement of the interlocking screws into the nail. In this syndrome, extensor hallucis longus weakness is noted and decreased sensation is seen in the 1st dorsal webspace (deep peroneal nerve distribution). These symptoms generally begin improving by 3 months and have variable rates of recovery.

Robinson et al. reported on 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, without clinical involvement of extensor digitorum longus or tibialis anterior. They found this in 5% of their patients after tibial nailing of closed tibia fractures, and all recovered either partially or completely by 4 months.

Lawrence et al. performed an anatomic study that reported the deep peroneal nerve was located superficial to the anterior tibial artery between the tibialis anterior and extensor hallucis longus muscles in the distal one third of the leg. They also found that the deep peroneal nerve crossed deep to the extensor hallucis longus tendon to enter the interval between the extensor hallucis longus and extensor digitorum longus at an average distance of 12.5 mm proximal to the ankle.

(OBQ11.54)
A 35-year-old male suffers the injury seen in Figures A and B following a motor vehicle collision. He is initially taken to a local hospital. The treating surgeon, concerned that his hospital does not have a plastic surgeon available for soft-tissue coverage, arranges for transfer of the patient to a nearby level I trauma center for definitive care. Upon arrival at the definitive treatment center, the patient is taken for formal debridement and external fixator application. Which of the following options has the greatest effect on this patient's risk of infection?Review Topic

Figures A and B demonstrate an open, segmental tibia shaft fracture with extensive soft-tissue injury. Recent evidence has demonstrated that time to transfer to a definitive trauma center has a significant effect on the incidence of infection for high-energy, open lower extremity fractures.

Pollak et. al analyzed a subgroup of 315 patients with high-energy, open lower extremity fractures from the Lower Extremity Assessment Project (LEAP study). Time to admission to a definitive trauma center for treatment was a significant, independent predictor of infection, with patients transferred 11-24 hours following injury having a significantly increased risk of major infection as compared with patients transferred within 3 hours of injury.

Werner et. al reviewed the existing literature surrounding the urgency of surgical debridement for open fractures, specifically relating to the "6 hour rule". The authors found limited evidence in the current literature to support emergent debridement within 6 hours of injury, and recommend urgent debridement (within 24 hours) once the patient is physiologically stable, life threatening emergencies have been addressed, and adequate surgical staff and resources are available.

Incorrect Answers:
1. External fixator application, although important for limb stability and ongoing assessment of the soft-tissue envelope, has not been shown to affect the rate of infection for open fractures
2. Tetanus prophylaxis is only effective against one infectious organism
3. Time to debridement was not shown to affect the rate of infection in the referenced articles
4. Time to soft-tissue coverage was not shown to have a statistically significant difference on the rate of infection in the level II study by Pollak et. al

(OBQ11.224)
A 54-year-old female sustains a communited tibial shaft fracture from an accident at work. She undergoes simultaneous external fixation and ORIF using minimally invasive plate osteosynthesis. Following surgery, she complains of numbness along the dorsum of her medial and lateral foot. In which location (labeled A - E) on Figure A did percutaneous placement without careful dissection of a pin/screw likely cause her nerve injury?Review Topic

The above clinical scenario describes a post-op superficial peroneal nerve (SPN) deficit following ORIF of a tibial fracture using both external fixation and minimally invasive plate osteosynthesis (MIPO). The less invasive stabilization system (LISS) plate by Synthes is a system which utlizes the MIPO technique. This minimally invasive technique can increase the risk of damage to the SPN without careful identification of the nerve distally due to its close proximity to LISS plate holes 11-13.

Deangelis et al studied the anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the LISS plate using cadaveric dissections. They found that the superficial peroneal nerve is at significant risk during percutaneous screw placement in holes 11 through 13 of the 13-hole proximal tibia LISS plates. They recommended using an incision and careful dissection down to the plate in this region of distal locking screws to minimize the risk of damage to the nerve.

Roberts et al also studied neurovascular anatomy of the leg in relation to screw placement, but did it in relation to locking screws used in intramedullary nailing. They concluded that intramedullary nail locking screws placed from a lateral-to-medial direction minimized the risk of injuries to the SPN and tibial neurovascular bundle. A disadvantage of lateral-to-medial locking screw placement was less resistance to nail bending forces.

If a hypertrophic nonunion is present, it is most likley a mechanical issue. Tibial diaphyseal hypertrophic nonunions (Illustration A) have approximately an 85-90% incidence of union with exchange reamed nailing. A nonunion that has bone loss or appears atrophic (Illustration B) will usually require improved mechanical stability as well as biological stimulation in the form of either autograft or an osteoinductive substance like BMP. A bone defect of up to 5-6cm in length can usually achieve union with bone grafting. In the presence of an infected nonunion, the infectious process needs to be addressed prior to the introduction of any revision hardware. If a patient does not show radiographic signs of tibial fracture union for 9 months and does not have progression toward healing for 3 consecutive months, then revision surgery would be indicated.

Tempelman et al looked at 71 tibial shaft fractures treated with nonlocked or dynamically locked IM nails and found a loss of alignment in 11% of the fractures that were not transverse in nature. They concluded that these nailing techniques should not be used in the treatment of spiral or oblique tibial shaft fractures.

Incorrect Answers:
1-A 4cm bone defect could not be corrected with exchanged nailing alone, and would either need extensive grafting or bone transport
2-An infected tibial shaft nonunion would require infection clearance prior to exchanged nailing
4-Atrophic nonunions typically need biologic stimulation in the form of acute grafting or insertion of a BMP type substance
5-Hypertrophic metadiaphyseal distal tibial nonunions can be treated with isolated exchanged nailing, however this does not have the same success as diaphyseal injuries. It is difficult to acheive appropriate stability to allow for fracture healing in the metadiaphyseal region, and other modalities such as plating need to be considered.

(OBQ10.217)
A 27-year-old female sustains a twisting injury to her leg while rollerblading. Radiographs of the tibia and fibula are provide in Figures A and B. A closed reduction is performed and the patient is placed in a long leg cast. Radiographs following cast placement are provided in Figures C and D. The decision is made to proceed with closed treatment instead of operative. Which of the following is most likely to occur with nonoperative management?Review Topic

The radiographs demonstrate a distal third spiral tibia shaft with a proximal fibula fracture. The coronal and sagittal alignments are within acceptable limits. The oblique fracture is at risk of shortening, especially with a concomitant fibular fracture.

Sarmiento et al. reviews fracture bracing for the treatment of long bones. With reference to tibial fractures, bracing is best for transverse fractures. Shortening is difficult to control in oblique fractures. However, shortening is usually less than 15 mm and does not result in functional limitations. He reports union in 97% of tibial fractures treated with bracing.

One year follow-up radiographs are provided in Illustrations A and B. The patient presented in this question went on to functional healing.

(OBQ09.187)
A 45-year-old female pedestrian is hit by an automobile. A clinical photo and radiograph are shown in Figure A and B. What is the most important factor in a surgeon's decision of determining between limb salvage and amputation? Review Topic

The clinical photo and radiograph are consistent with a Grade III open tibia fracture.

The referenced study by the LEAP group reviews 527 patients with severe lower extremity fractures and found that the most important factor in determining the ability to salvage the extremity remains the severity of the soft tissue injury of that extremity. Bone loss has been shown to have no effect on the eventual outcome (amputation versus salvage). Similarly, plantar sensation at presentation has no bearing on final outcome, and in the LEAP study, often either partially or fully returned.

The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures.

(OBQ09.228)
A 21-year-old male sustains the open injury shown in Figure A, which is associated with a 12 centimeter laceration over the fracture site. This laceration is able to be closed during initial surgery. What adjunct treatment has been shown to improve outcomes when using an intramedullary nail?Review Topic

(OBQ09.246)
Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?Review Topic

Placement of long lateral tibial plates have been shown to have a risk of iatrogenic injury to the superficial peroneal nerve, which has a sensory distribution to the dorsal foot. This risk is seen especially with percutaneous approaches, such as those used with the LISS plate.

The first reference by Deangelis et al found a risk of superficial peroneal injury with percutaneous screw placement of holes 11-13 in the LISS plate.

The second referenced article by Roberts et al noted a slightly increased distance to the neurovascular bundle when interlocking tibial nails in a lateral to medial direction (compared to medial to lateral locking) and slightly increased biomechanical strength when locking in a medial to lateral direction.

The third referenced article by Wolinsky et al notes a risk of iatrogenic injury to the deep peroneal nerve and anterior tibial artery with an anterolateral approach to the distal tibia, but notes the superficial peroneal nerve is safe with an appropriate exposure.

Reamed exchange intramedullary nailing of diaphyseal tibial shaft fractures in which there is less than 30% of cortical bone loss can achieve union rates ranging between 76%-96%. In a review article, Brinker et al discusses the indications and limitations of exchange nailing of ununited fractures. Biological as well as mechanical factors contribute to the healing of nonunions. Anatomically, multiple studies cited in this review article demonstrate that distal femoral nonunions do not readily achieve union following exchange nailing. Humerus nonunions, both diaphyseal and proximal locations, more readily achieve union with plate fixation and bone grafting according to articles cited in this review as well. Banaszkiewicz et al also discusses the difficulties with exchange nailing of femoral nonunions with a large percentage of patients requiring additional surgeries to achieve union. Templeman et al discusses the successful results of reamed exchange intramedullary nailing of delayed union and nonunion of the tibial shaft. The authors recommend the use of bone graft only when there is substantial bone loss, usually exceeding 30% of the cortical diameter.

(OBQ07.76)
A 32-year-old male sustains the injury shown in Figure A and undergoes treatment as shown in Figure B. Following placement of this implant, what is the best technique to confirm it is not too proud proximally? Review Topic

The safe zone for tibial nail placement as seen on radiographs is just medial to the lateral tibial spine on the anteroposterior radiograph and immediately adjacent and anterior to the articular surface as visualized on the lateral radiograph.

Tornetta et al specifically located the safe zone for nail entry in a study using fresh frozen cadaver knees. The authors found that the safe zone for nail placement is located 9.1+/-5 millimeters lateral to the midline of the plateau and three millimeters lateral to the center of the tibial tubercle. The width of the safe zone averaged 22.9 millimeters and was as narrow as 12.6 millimeters.

The starting point of the of the nail can be best viewed on the lateral knee radiograph, an example of which is shown in Illustration A. Illustration B shows the "sweet spot" for nail insertion as defined by Tornetta.

(OBQ07.126)
Which of the following factors has been shown in a clinical trial to be equivalent to autologous bone graft for treatment of tibial nonunions that were treated with intramedullary nailing?Review Topic

Osteogenic Protein-1 (OP-1), which is also known as BMP-7, has been evaluated in a randomized, prospective, multi-institution study of tibial nonunions.

Between 5% to 10% of tibial shaft fractures progress to nonunion, causing substantial disability. Bone autografts, along with internal fixation, are the usual treatment for these failures, but the morbidity associated with autogenous tissues remains problematic. Bone morphogenetic proteins are currently available for clinical use and preclinical models, and an increasing number of patients treated with these molecules demonstrate their safety and efficacy.

Swiontkowski et al performed a level I study of patients with acute open tibial fractures randomized to treatment with or without rhBMP-2. Interestingly, in their subgroup analysis the authors found no significant difference between the two groups when patients were treated with reamed intramedullary nailing.

(OBQ07.182)
A 45-year-old male presents with the fracture seen in Figures A and B after a motor vehicle collision. After debridement and external fixation, he is taken to the operating room for definitive soft tissue flap coverage and intramedullary nailing. Administration of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) at the time of fracture fixation will lead to which of the following?Review Topic

Administration of rhBMP-2 at the time of definitive fixation has been shown to decrease the need for subsequent bone grafting procedures in Gustilo-Anderson type IIIA and IIIB open tibia fractures.

Swiontkowski et al performed a subgroup analysis of two prospective randomized control studies regarding the use of rhBMP-2 in open tibia fractures. The authors found a significant risk reduction in the need for secondary procedures, including bone grafting, with the addition of rhBMP-2 for type IIIA and IIIB open tibia fractures.

Govender et al performed a randomized prospective RCT of 450 patients with open tibia fractures allocated to tibia nailing or nailing with one of 2 different dosages of rhBMP-2. They found a 44% reduction in the need for secondary intervention as a result of delayed union, better wound healing, and decreased infection in the higher dose rhBMP-2 group compared to controls.

(OBQ06.64)
A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. The patient is at greatest risk of developing which of the following conditions as a result of this malunion?Review Topic

A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.

The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.

The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

Puloski et al determined the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography. Malrotation was defined as an internal/external rotation deformity greater than 10 degrees. They found that 5 (22%) of the tibia were malrotated greater than 10 degrees, and of those 5 tibia, 4 were distal 1/3 fractures.

McKee et al randomized 85 patients undergoing intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction. They found that manual traction is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures.

(OBQ06.193)
A 25-year-old man is struck by car while crossing the street. His injuries include the closed left tibial shaft fracture shown in Figure A. He is a smoker, but is otherwise healthy. Intramedullary nailing is performed without initial complications. Which of the following puts this patient at greatest risk for tibial nonunion? Review Topic

Post-operative gapping at the fracture site significantly increased the risk of reoperation due to nonunion or malunion.

Bhandari et al performed a retrospective study to identify which prognostic factors were associated with an increased risk of reoperation for nonunion in surgically treated tibial shaft fractures. They examined over 200 fractures, and found the presence of an open fracture wound (RR 4.32), lack of cortical continuity between the fracture ends following fixation (RR 8.33), and the presence of a transverse fracture (RR 20.0) were the three variables most predicitive of reoperation.

Audige et al analyzed 416 patients with operatively treated tibial shaft fractures who were followed for at least 6 months. They found that the greatest risk for delayed healing or nonunion was the presence of an open injury, fractures of the distal 1/3 of the tibia, and postoperative gapping at the fracture site (The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis).

(OBQ05.79)
A 25-year-old male is a driver in a motor vehicle accident and sustains the isolated closed injury seen in Figures A and B. He is treated with an intramedullary nail, and postoperative radiographs are shown in Figures C and D. Which of the statements concerning reaming and nails is true?Review Topic

The patient in the scenario has a closed distal one-third tibia fracture. Canal reaming increases the biologic environment for fracture healing but can potentially disrupt cortical blood flow. As such, many recommend canal reaming 1-2mm greater than the canal width followed by insertion of a nail that matches the native canal width. Reamed and unreamed tibias have similar mineral apposition rates.

In 1998, Hupel et al studied the effect of loose and tight unreamed, locked nails on cortical blood flow and strength of union in a canine model. They found that loose nails allowed higher cortical reperfusion at the time of insertion and at eleven weeks.

In a later study by the same group in 2001, they studied the effect of non-reamed, limited reamed and standard reamed nails on porosity, new bone formation and mineral apposition. They found the lowest porosity in the limited reaming group but found new bone formation and mineral apposition rates similar at eleven weeks across the three groups. They concluded that limited reaming is preferred in patients with vascular compromise to the tibia.

Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during transtendinous nailing was thought to be a contributing cause of chronic anterior knee pain.

The referenced paper by Toivanen et al. compared two different nail-insertion techniques in 50 patients who were randomized to treatment with paratendinous or transtendinous nailing. Sixty-seven percent of the transtendinous and seventy-one percent of the paratendinous approaches resulted in patients with postoperative anterior knee pain. The same authors published an 8 year follow-up which showed that the percentage dropped down to 29%, but there was still no advantage of paratendinous over the transtendinous approach.

In the more recent study by Lefaivre with an average patient follow up of 14 years, knee pain was present in greater than 70% of the respondents.

(OBQ05.171)
A 36-year-old male is brought to the trauma center following a motor vehicle accident. Physical exam shows a deformed left lower extremity with a 1-cm open wound over the anterolateral aspect of his leg. Radiographs are provided in Figures A and B. Which of the following interventions has been shown in the literature to decrease the occurrence of infection at the fracture site?Review Topic

QID:1057

FIGURES:

A

B

1

Operative debridement within 6 hours of injury

8%

(83/1024)

2

Immediate prophylactic antibiotic administration

87%

(889/1024)

3

Immediate stabilization with internal fixation after debridement

3%

(27/1024)

4

Irrigating with a saline solution that is mixed with an antibiotic

1%

(8/1024)

5

Irrigating with high pressure pulsatile lavage following surgical debridement

The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.

Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow.

(OBQ05.192)
When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT?Review Topic

The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibula and tibial shortening >2cm).

(OBQ05.216)
A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation?Review Topic

Superficial peroneal nerve (SPN) injury is a known complication of percutaneous plating of proximal tibial fractures with the LISS system as seen in Figure A.

The Less Invasive Stabilization System (LISS) is a minimally invasive implant that uses indirect fracture reduction techniques. When using the LISS system, percutaneous screw placement increases the risk of injury to nearby structures because they are not necessarily visualized. The superficial peroneal nerve exits the superficial fascia of the leg approximately 8 cm above the tip of the lateral malleolus. The nerve then travels from posterior to anterior in the vicinity of the distal aspect of the 13-hole proximal tibia LISS plate (near holes 11-13). In a patient of shorter stature, the nerve could cross the distal portion of a 9-hole plate.

Deangelis et al. performed a cadaveric study using Less Invasive Stabilization System (LISS) plates and found that the average distance from the SPN to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm respectively. They recommended using a larger incision and careful dissection down to the plate in this region to minimize the risk of damage to the nerve.

Cole et al. retrospectively reviewed 77 tibia fractures treated with LISS and found that 91% healed without complication. In their cohort, there were no superficial peroneal nerve palsies and one deep peroneal nerve palsy.

Figure A demonstrates AP and lateral x-rays of a tibial shaft fracture treated with a LISS plate.

Incorrect Answers:
A: compartment syndrome would have demonstrated pain out of proportion which the patient never complains of
B, D, and E are all less likely to be injured with LISS plate application than the superficial peroneal nerve.

(OBQ04.27)
Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?Review Topic

Valgus and flexion is the most common deformity seen after intramedullary nailing of proximal tibia fractures. The semi-extended nailing position helps overcome the procurvatum or flexion deformity of the fracture.

Lang et al. reported in their study of 32 proximal third tibia fractures that 56% of the fractures had 5 degrees or more valgus angulation and 28% had 10 degrees or more valgus angulation. Angulation in the AP plane ranged from 0 degrees to 20 degrees, all of which was apex anterior. Nineteen (59%) fractures demonstrated 5 degrees or more angulation, and 7 (22%) fractures demonstrated 10 degrees of more angulation.

Tornetta advocates use of extended medial parapatellar incision with the leg in a semiextended position to allow for a more proximal and lateral starting point. This modified starting point forces the nail to overcome the tendency of the fracture to flex (apex anterior) and go into valgus.

(OBQ04.34)
A 35-year-old male has a closed mid-shaft tibia fracture following a skiing accident. You have recommended intramedullary nailing of the tibia. What is the most common complication he must be advised about?Review Topic

Chronic anterior knee pain at the insertion site is the most common frequently reported complication of closed nailing of a tibial shaft fracture. A high incidence of knee pain has been associated with IM nailing. The etiology of anterior knee pain remains unclear. It had been previously thought that the incidence of pain is higher when the nail was inserted by a patellar tendon-spliting approach versus a paratendon approach. According to the Keating paper, insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Toivanen et al. investigated this question when the group randomized fifty patients with a tibial shaft fracture requiring intramedullary nailing equally to treatment with paratendinous or transtendinous nailing. Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.

(OBQ04.69)
A 40-year-old woman is involved in motorcycle accident 2 hours ago and sustains an isolated right leg injury shown in Figure A. She has dopplerable posterior tibial and dorsalis pedis artery signals with less than 2 second capillary refill as shown in Figure B. Sensation is intact in the distribution of the tibial nerve but decreased in the distribution of the peroneal nerve. She is cleared by the general surgery trauma team to go to the operating room for treatment of her leg. What is the most appropriate Gustilo classification and initial treatment for her injury?Review Topic

The injury described above is a Type IIIB injury as per the Gustilo and Anderson classification. Type I injuries are low energy and have small soft-tissue wounds (usually <1 cm in length) with minimal contamination. Type II injures have a wound >1 cm in length, but do not have extensive soft-tissue damage, flaps, or avulsions. Type IIIA injuries are associated with soft-tissue damage secondary to high-energy trauma but have adequate soft-tissue coverage. Type IIIB injures exhibit severe periosteal stripping and bone exposure, often associated with massive contamination. These often require treatment with soft-tissue coverage procedures. Type IIIC fractures require vascular repair. The risk for infection in this scenario is as high as 44%, so placing definitive plate fixation is contraindicated when future debridement and soft tissue coverage procedures will be needed. External fixation provides excellent stability, provisional skeletal alignment, and minimal additional soft tissue injury.

(OBQ04.114)
A 56-year-old male sustains a Type IIIB open, comminuted tibial shaft fracture distal to a well-fixed total knee arthroplasty that is definitively treated with a free flap and external fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Laboratory workup for infection is negative. Passive knee range of motion is limited to 15 degrees. What is the most appropriate treatment for his nonunion?Review Topic

At 9 months, observation is no longer an option, as the fracture is not healing and is adjacent to a arthrofibrotic joint. Plate osteosynthesis has been shown to be an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and/or immobilization in a cast.

Wiss et al reported a series of fifty tibial non-unions with a similar clinical scenario. He reported that, with compression plating, 92% of the nonunions healed without further intervention. In their study, 39/50 patients, had autogenous bone grafting in addition to compression plating.

(OBQ04.194)
A 32-year-old male sustains the closed injury shown in Figure A. He undergoes reamed intramedullary nailing 4 hours after his injury. Postoperative images are shown in Figures B and C. Compared to unreamed nailing, reamed nailing of this injury has been associated with which of the following?Review Topic

Reamed nailing of closed tibial shaft fractures has been shown to lead to an earlier time to union without an increased rate of complications when compared to unreamed nailing.

The referenced study by Finkenmeier et al is a randomized controlled study of reamed vs. unreamed nails in open and closed tibia fractures (excluding Grades IIIB and IIIC). They found that the use of reamed insertion of IM nails for the treatment of closed tibia fractures lead to an earlier time to union without increased complications. The authors reported no differences in infection rate, compartment syndrome rate, or percent needing additional surgeries to obtain union. More secondary procedures were needed with unreamed nails in closed fractures only. Increased rates of interlocking screw failure were seen if smaller screws were needed for smaller, unreamed nails.

The referenced study by Keating et al reported that reaming for open tibia fractures is safe, with time to union and nonunion rate increasing with increased soft tissue injury as classified by the Gustilo-Anderson classification.

Bhandari et al conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. When comparing outcomes in open and closed injuries at twelve months, they found a benefit for reamed intramedullary nailing in patients with closed fractures, but found no difference between approaches in patients with open fractures.

Figure A shows a tibial shaft fracture, with intramedullary fixation shown in Figures B and C.

By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.

Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.

Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is less commonly indicated in the proximal and middle tibia.

(OBQ04.256)
A 42-year-old male sustains a left leg injury as the result of a high-speed motor vehicle collision. Physical exam reveals a grossly deformed left leg with a 1 centimeter open wound over the anterolateral aspect of his tibia; no gross neurovascular deficits are noted. Injury radiographs are shown in Figures A and B. He undergoes immediate tibial nailing with debridement and primary closure of his traumatic wound. Which of the following is the Gustilo-Anderson classification for his fracture?Review Topic

Figures A and B show a significantly comminuted, segmental tibial fracture. In this scenario, the fracture is appropriately classified as a Grade III because there is a highly comminuted, segmental fracture which is always associated with significant periosteal stripping. The patient's leg was able to be closed primarily, which means that it should be classified as a IIIA.

Gustilo et al reviews 18 years of open fracture treatment and outcomes. They reported that débridement and copious irrigation, with primary closure for type I and II fractures and secondary closure for type III fractures resulted in a 5% infection rate (9% for type III fractures). Initial wound cultures were positive in 70.3% despite an infection rate of that patient group of only 2.5%.